Geraldo Verginelli

Surgical Treatment of Ruptured Aneurysms of the Innominate Artery

The cases of 3 patients with an aneurysm of the innominate artery treated surgically are reported. The clinical manifestations were different, and the surgical procedures employed also varied. In 1 patient, the neck of the aneurysm was isolated and clamped near the aortic arch. It was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. In the second, the aneurysm was resected under cardiopulmonary bypass, deep hypothermia, and total circulatory arrest. The neck was closed with a large Teflon patch, and a tube graft was interposed between the ascending aorta and the right carotid artery. In the third, a graft was interposed between both carotid arteries; conventional cardiopulmonary bypass was instituted, and the aorta was clamped between the innominate and the left carotid arteries. The neck of the aneurysm was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. All patients had an excellent postoperative course. Our comments regarding the clinical and surgical aspects of this condition are based on the present experience and reports in the literature.

Fatores prognósticos na revascularização do miocárdio em pacientes idosos

The trend in Brazil of erroneously delaying myocardial revascularization in the elderly determined this study. Three hundred consecutive elderly patients (mean age: 73,92, standard deviation: 3.32). Between October 1992 and July 1995, 361 consecutive patients underwent isolated coronary artery bypass grafting, of whom 111 (30,7%) were females and 250 (69,35) males. There were 128 (35,5%) diabetic patients and 128 (36,7%) were in NYHA III/IV. Univariate analysis per-operatory of 19 factors followed by multivariate logistic regression analysis of the significant variables (p 0.005) were done. Major complication ocurred in 178 (49.3%) and were independent predictors of operative morbidity: Diabetes mellitus, NYHA funcional classification, urgent cases and DP2. There were 33 (9,1%) in hospital deaths, and diabetes mellitus, NYHA functional classification, unstable pre-operative angina and cerebral vascular acidents, renal failure, infection and insufficiency respiratory failure were independent predictors of operative mortality. We concluded that coronary artery bypass grafting is possible in elderly patients with a favorable outcome, especially when done in patients with normal to moderately depressed left ventricular function.

Plástica da valva mitral: resultados aos 17 anos de experiência

From March 1980 to December 1997, 545 patients underwent 560 mitral valve repairs at the Heart Institute of HCFMUSP. Ages ranged from 3 months to 86 years with mean age of 42.2 and standard deviation of 21.4 years. Two hundred and seventy four (50.3%) were male. Ethiology was rheumatic disease in 234 (42.9%) patients. The techniques used were: quadrangular resection of posterior leaflet in 204 (36.5%) patients, annuloplasty with posterior sling in 139 (24.5%), Carpentier ring annuloplasty in 102 (18.2%), segmentary posterior annuloplasty in 37 (6.6%) and others. Associated procedures were performed in 267 (35.6%) patients with the most frequent tricuspid valve repair in 95 (17%) patients. Immediate mortality was 3.7% (21 patients). The linearizated rates of reoperation, thromboembolism, endocarditis and hemolysis, were respectively 2.9%, 0.6%, 0.3% and 0.1% patient/ year. The actuarial survival rate at 17 years was 76.8 ± 10.8% and the actuarial freedom from endocarditis, thromboembolism, reoperation and hemolisis at 17 years was 98.9 ± 0.6%, 93.9 ± 3.7%, 61.0 ± 7.9% and 99.7 ± 0.2%, respectively. We conclude that patients submitted to mitral valve repair presented satisfactory evolution.

Plástica da valva mitral em portadores de febre reumática

Purpose: To analyze the late results of mitral valve repair in rheumatic patients. Material and Methods: Between March 1980 and December 1997, 201 rheumatic patients underwent mitral valve repair in the Heart Institute of HCFMUSP. Average age was 26.9 ± 15.4 years and 59.6% were female. Other diagnoses were present in 67.7% of patients and the most common was tricuspid regurgitation (31.3%). The techniques of repair were: Carpentier ring annuloplasty in 75 (37.3%), posterior annuloplasty with pericardial sling in 68 (33.8%), posterior segmental annuloplasty in 16 (7.9%), quadrangular resection of the posterior leaflet in 11 (5.5%), partial resection of the anterior leaflet in 6 (3%), De Vega type annuloplasty in 6 (3%), Kay in 5 (2.5%), Reed in 4 (2%) and others in 10 patients. Associated techniques were employed in 94 patients (46.8%), the most frequent was chordal shortening (48 patients - 23.9%). Associated procedures were performed in 113 patients (56.2%). The actuarial curves (Kaplan-Meier) were compared through linear regression analysis. Results: Hospital mortality was 4 patients (2.0%) and the causes were multiorgan failure in 2 (50%) and low cardiac output in 2 (50%). In the late postoperative period, 83.9% of the patients were in functional class I (NYHA). The actuarial survival was 93.9 ± 1.9% in 125 months. Twenty three patients were reoperated in the post-operative period with a mean interval of 35.7 months. The actuarial freedom from reoperation was 43.3 ± 13.7% in 125 months. Comparing the patients according to age, in the group over 16 years (group 1), the actuarial survival was 91.3 ± 3.8%, against 95.6 ± 2.7% in the group with more than 16 years (group 2), with a statistic difference (p < 0.0001). Freedom from reoperation was 50.8 ± 16.9% in group 1 and 47.0 ± 14.9% in group 2 (p < 0.0001). Conclusions: Late results with mitral valve repair in rheumatic mitral insufficiency were satisfactory.

Biopróteses de pericárdio bovino Fisics-Incor: 15 anos

Between March 1982 and December 1995, 2607 Fisics-Incor bovine pericardial bioprostheses were implanted in 2259 patients. The average age was 47.2 ± 17.5 years, and 55% were male. Rheumatic fever was present in 1031 (45.7%) patients. We performed 1073 aortic valve replacements, 1085 mitral replacements, 27 tricuspid replacements, 195 mitral-aortic replacements, and other 16 combined valve replacements. There were associated procedures in 788 (32.9%) patients, the most frequent being tricuspid valve repair (9.2%) and myocardial revascularization (7.7%). The hospital mortality was 194 (8.6%) patients, 8.6% for the mitral group, 4.7% for the aortic, and 12.8% for the double valve replacements. The linearized rates for calcification, thromboembolism, rupture, leak and endocarditis were, respectively, 1.1%; 0.2%; 0.9%; 0.1% and 0.5% patient-year. The actuarial survival curve was 56.7 ± 5.4% in 15 years. Free from endocarditis was 91.9 ± 2%, thromboembolism 95 ± 1,7%, rupture 43.7 ± 9.8%, leak 98.9 ± 4.5%, and calcification 48.8 ± 7.9% in 15 years. In the late post-operative period, 1614 (80.6%) patients were in NYHA functional class I. We conclude that the results with the Fisics-Incor bovine pericardial bioprostheses were satisfactory in our group of patients.

Plástica da valva mitral: resultados tardios de doze anos de experiência e evoluçäo das técnicas

Foram estudados 301 pacientes, sendo 151 (50,2%) do sexo masculino, com idade variando de 3 meses a 79 anos (media de 37,96 com desvio padrao de 21,4 anos). A etiologia das lesoes foi reumatica em 128 (42,52%), degenerativa em 78 (25,91%), congenita em 21 (6,97%), isquemica em 18 (5,98%), endomiocardiofibrose em 9 (2,99%), endocardite infecciosa em 8 (2,65%), valvulite cronica inespecifica em 5 (1,66%), e nao definida em 34 (11,29%) pacientes. Duzentos e quatro (67,8%) pacientes apresentavam insuficiencia mitral e 97 (32,2%) dupla lesao mitral. Cirurgia associada foi realizada em 45% dos pacientes sendo a mais frequente a substituicao da valva aortica em 41 (13%) pacientes. As principais tecnicas utilizadas foram: resseccao quadrangular da cuspide posterior em 97 (30,99%) pacientes, associada a deslizamento em 3, anel de Carpentier em 93 (29,71%), e tira posterior em 76 (24,28%) pacientes. Encurtamento de cordas tendineas foi realizado em 56 pacientes e encurtamento de papilar em 6. A mortalidade imediata foi de 12 (3,9%) pacientes. Foram reoperados no pos-operatorio imediato 3 (0,9%) pacientes por disfuncao da plastica. As taxas linearizadas para tromboembolismo, morte, replastia e troca valvar mitral no pos-operatorio tardio foram respectivamente 0,2%, 0,5%, 1,0% e 1,1 % pacientes/ano. A curva actuarial de sobrevida e de 83,6% em doze anos e a curva actuarial livre do evento reoperacao e de 83%. Setenta e nove por cento dos pacientes encontram-se em classe funcional I (NYHA) no pos-operatorio tardio (evolucao de 10077 meses/pacientes). Podemos concluir que os pacientes submetidos a plastica da valva mitral apresentaram evolucao satisfatoria, e que o aprimoramento das tecnicas com o passar dos anos tem contribuido para melhoria dos resultados.

Reoperações valvares: experiência do InCór-FMUSP

Neste trabalho comparamos os resultados da mortalidade nas reoperacoes valvares, a fim de estabelecer a gravidade das reoperacoes conservadoras e das retrocas, analisando a influencia do numero de procedimentos nos resultados. Foram estudados 296 pacientes cujas idades variaram de cinco a 72 anos, com media de 34,5 anos. Duzentos e oito pacientes foram submetidos a reoperacao mitral, sendo realizada recomissurotomia em 23 (7,8%) pacientes, terceira comissurotomia em dois (0,7%), primeira substituicao mitral em 26 (8,8%), segunda troca mitral em 127 (42,9%), terceira troca em um (0,3%). Reoperacao em valva aortica foi realizada em 67 pacientes, sendo primeira troca aortica por reestenose em cinco (1,7%) pacientes, segunda troca em 28 (16,2%), terceira troca aortica em 11 (3,7%) e quarta troca em tres (1%). Retroca mitro-aortica foi realizada em 19 (6,4%) pacientes, retroca tricuspide em um (0,3%) e retroca mitrotricuspidea tambem em um (0,3%) pacientes. A mortalidade na recomissurotomia mitral foi de 0% (0/26); na primeira troca mitral foi de 15,4% (4/26); na segunda troca 15,0% (19/127); na terceira troca 15,4% (4/26); na quarta e quinta trocas (4 casos) mitrais nao houve mortalidade. Na primeira troca aortica a mortalidade foi de 40% (2/5); a segunda substituicao aortica foi de 14,6% (7/48); na terceira nao houve mortalidade (0/11) e na quarta a mortalidade foi de 100% (3/3). Na segunda substituicao mitro-aortica a mortalidade foi de 10,5% (2/19). A analise estatistica dos dados nao demonstrou relacao entre a mortalidade e o numero de operacoes previamente realizadas.

Potassium in cardiac surgery with extracorporeal perfusion

Abstract Serum and urinary potassium variations during cardiac surgery with extracorporeal perfusion and in the immediate postoperative period were studied in 50 patients. The patients were divided into four groups: those with (1) congenital lesions; (2) cyanotic congenital lesions; (3) acquired lesions without diuretic therapy in the preoperative period; and (4) acquired lesions with diuretic therapy in the preoperative period. The uniform decrease in serum potassium during perfusion was confirmed in the four groups. In group II preoperative potassium levels were below normal range. In group IV low potassium levels were observed in the preoperative period, associated with respiratory alkalosis; subjects in this group had more instances of arrhythmias in the postoperative period than those in the other three groups. In the absence of dilutional or urinary potassium loss, the decrease in serum potassium is probably a consequence of its penetration into the body cells. Respiratory alkalosis due to anesthetic hyperventilation is an important factor contributing to this change.

Artéria radial na ampliaçäo do uso de enxertos arteriais para revascularizaçäo do miocárdio: consideraçöes anatômicas e tática cirúrgica

The aim of our study is to determine the microscopical anatomy imunohistochemistry and electronical scanning analysis of the radial artery (RA); 269 patients underwent myocardial revascularization with a RA graft were studied, performing 319 RA anatomoses; 80.7% patients were male and 93.7% Caucasians. The left internal thoracic artery (LITA) was used in 246 patients at the present surgery and 17 LITA were used before (redo-operation), performing 97.8%. LITA conduits employed altogether. The patients received another additional conduits: 59 (21.9%) right internal thoracic arteries (RITA); 17 (6.3%) right gastroepiploic arteries (RGEA); 161 (59.8%) saphenous vein grafts. An average of 3.4 anastomoses/patient were constructed. There was no post-operative complications such as ischemia or infection envolving the hand with interruption of the RA supply. The RA immunohistochemistry and electronical scanning microscopy showed that the internal elastic layer is developed and the media layer presented muscular fibers sheafs surrounded by collagen fibers more than elastic fibers. The post-operative complications include respiratory distress (21 -7.8%), atrial fibrillation (21 -7.8%), and enzymatic or electrocardiographic signs (12-4.5%) of acute myocardial infarction. Six (2.2%) patients needed mechanical support with intraortic balloon pump. Early angiographic controls have been performed in 21 patients. One patient developed RA dissection during the angiographic study; in all other patients the RA patency was 100%. The overall in-hospital mortality rate was 2.2% (6 patients). Recently, different arrangements of the arterial grafts were adopted to achieve a more complete myocardial revascularization. The RA are frequently employed to sequential anastomosis with the inferior and lateral left ventricular coronaries. The RA proximal anastomosis is often performed with the LITA. Both the RGEA and the RITA are used as complementar arterial grafts. From 64 patients submitted to myocardial revascularization with RA last 3 months, 2 arterial conduits were performed in 62 (96.9%) patients, 3 arterial conduits were performed in 27 (42.2%) patients and 4 or 5 arterial conduits were performed in 8 (12.5%). Although the pedicled internal thoracic artery graft remains the primary arterial conduit for myocardial revascularization, the radial artery is an excellent additional bypass conduit.

Angiossarcoma de átrio direito

A 19 years-old-female with primary right atrial angiosarcoma partially obstructing the tricuspid valve, developed severe hypoxemia due-to-right to left shunting through a patent foramen ovale. This is the first report of such a clinical situation with this type of tumor. A complete resection of the tumor was attempted, and the right atrium had to be rebuilt with a bovine pericardial patch. Postoperative cranial, thoracic and abdominal CT scans and bone scintigraphy did not show metastatic spread. Chest radiation therapy was started on the third postoperative week. Chemotherapy was not used. The patient died a few months after surgery due to disseminated metastatic disease but no evidence of the tumor was found in the necroscopic study of the heart.